THE  PROGNOSIS 


TUBERCULOSIS 

...by... 


JOHN  J LLOYD,  Jr.,  M.D. 
CATAWBA  SANATORIUM 
VIRGINIA 


REPRINTED  from  the 
VIRGINIA  MEDICAL  SEMI-MONTHLY 
JULY  26,  1912 


Co  I •f.  5 4 % 

L 77 p 


f Reprinted  from  the  Virginia  Medical  Semi  Monthly,  J uiy  26, 1912) 


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THE  PROGNOSIS  OF  TUBERCULOSIS.* 

By  JOHN  J,  LLOYD,  Jr.,  M.  D.,  Catawba  Sanato- 
rium, Va. 

“How  long  will  it  take  me  to  get  well?”  or 
“Can  I get  well  ?”  is  the  question  we  are  usually 
called  upon  to  answer  as  soon  as  we  have  diag- 
nosed the  case.  It  is  because  we  each  have  to 
give  a prognosis  in  every  case  of  tuberculosis 
under  our  care  that  I have  chosen  this  as  the 
subject  for  this  paper. 

Prognosis  includes  any  result  from  coup 
plete  recovery,  i.  e.,  cure,  to  early  death, 
tient  effect  very  markedly  the  outlook  for  re- 
covery. A nervous,  high-strung  temperament 
and  a disposition  prone  to  pessimism,  and  fret- 
ting at  restraint,  make  a hard  patient  to  deal 
with.  On  the  other  hand,  the  nervousness  may 
be  due  largely  to  toxemia,  and  after  a few  weeks 
of  rest  these  patients  sometimes  come  to  be  ex- 
cellent ones,  and  lend  their  full  co-operation  to 
the  physician. 

gence,  a desire  to  get  well,  and  force  of  char- 

Tf  the  patient  has  a good  degree  of  intelli-  * 
acter  to  stick  at  it  in  spite  of  seeming  great  ob- 
stacles, then  we  feel  great  hope  for  the  future 
even  in  the  presence  of  an  advanced  stage  of  the 
disease. 

The  saying — “ISTone  but  the  rich  can  afford  to 
have  tuberculosis” — has  considerable  truth  in 


♦Read  before  the  Piedmont.  Medical  Society,  at  Char- 
lottesville, Va.,  January  20,  1912. 


it,  for  the  life  of  a pulmonary  invalid  is  of 
necessity  a little  more  expensive,  and  his  earn- 
ing capacity  usually  reduced,  but  while  this  is 
true  to  quite  an  extent,  the  public  generally  is 
realizing  more  than  ever  before  the  terrible  fre- 
quency of  tuberculosis  and  employers  are  lending 
their  aid  to  employees  in  helping  them  earn  a 
living  and  at  the  same  time  retain  their  health. 
It  is  after  a stay  in  a sanatorium  that  the  hard- 
est time  comes  for  the  tuberculous.  They  have 
exhausted  their  means  and  are  not  in  shape  to 
return  to  hard  physical  labor.  That  is  the  time 
for  friends  and  philanthropists  to  come  to  their 
aid  and  tide  them  over  the  period  of  semi-re- 
covery, when  they  are  neither  sick  enough  to  be 
in  a sanatorium,  nor  well  enough  to  return  to 
their  usual  work. 

Many  a woman  is  doomed  to  death  from 
tuberculosis  by  having  ignorant  and  fool- 
ish relatives.  A man  will  take  the  bull 
by  the  horns  and  do  what  he  is  told  in 
regard  to  dropping  everything  and  trying  to  get 
well,  but  a woman  under  similar  circumstances 
will  bow  to  the  wishes  of  relatives  or,  it  may  be, 
she  is  entirely  powerless  in  the  matter. 
When  we  meet  opposition  from  ignorant  rela- 
tives and  friends,  we  are  absolutely  helpless 
until  we  can  convince  them  or  convince  the  pa- 
tient in  spite  of  them. 

A change  of  surroundings  and  often  a change 
of  climate  will  in  many  cases  produce  wonder- 
ful results.  This  is  a well  knowu  fact  aud  one 


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which  has  been  used  in  the  treatment  of 
all  diseases  from  time  immemorial.  This 
is  one  reason  for  the  existence  of  sanatoria, 
but  their  chief  value  is  an  educational 
one.  In  sanatoria  patients  are  taught  what 
is  good  and  what  harmful  for  them,  and 
here  they  have  other  patients  as  object  les- 
sons. They  also  learn  how  to  protect  them- 
selves and  others  from  their  sputum  which  is 
of  such  vital  importance.  It  is  a great  mistake 
for  the  physician  to  tell  his  patient  that  a few 
weeks  or  months  will  cure  him,  for  it  always 
takes  a long  time. 

The  experience  and  personality  of  the  phy- 
sician count  for  a great  deal,  for  there  is  no 
disease  we  are  called  on  to  treat  which  requires 
more  tact,  patience,  and  common  sense  than  does 
tuberculosis.  The  patient  discussion  of  symp- 
toms, the  many  little  details  of  every-day  life, 
and  the  giving  of  explicit  directions  to  cover 
any  emergency  in  the  future  are  among  the 
duties  of  a physician  treating  tuberculosis.  He 
must  'be  willing  to  share  the  troubles  and  wor- 
ries, and  to  keep  posted  on  the  symptoms  of  the 
patient,  for  it  is  often  by  the  attention  to  little 
things  that  we  are  enabled  to  foretell  and  pre- 
vent some  serious  development. 

So  much  for  general  considerations : now  for 
the  symptoms  and  findings : — 

We  learn  considerable  from  the  character  of 
onset.  Generally  speaking,  the  more  acute  the 
onset  the  more  virulent  the  infection  or  the 


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lower  the  resistance,  and  to  a certain  degree  the 
reverse  is  true. 

The  stage  of  the  disease  at  the  time  of 
diagnosis  is  perhaps  the  most  important  single 
point  in  prognosis.  Recovery  in  incipient  cases 
is  estimated  at  from  60  to  80  per  cent.;  in 
moderately  advanced,  about  20  per  cent.,  and 
in  the  far  advanced  very  small  indeed,  perhaps 
less  than  one.  The  reason  for  this  is  readily 
understood  when  we  recall  the  fact  that  the 
tuberculous  focus  at  frequent  intervals  pours 
out  fresh  supplies  of  the  invading  bacilli  to  at- 
tack the  tissues.  This  invasion  is  met  by  the 
defensive  forces  of  the  organism,  the  leucocytes, 
antibodies,  lysins,  etc.,  and  if  the  defense  is 
stronger  than  the  offense,  the  process  is  limited, 
but  in  so  doing  the  defensive  products  are  used 
up  more  rapidly  than  the  bacilli  and  the  time 
will  be  reached,  sooner  or  later,  when  the  de- 
fensive forces  are  so  weakened  that  an  extension 
of  greater  or  less  degree  occurs.  Therefore,  if 
the  diagnosis  is  made  early  the  chances  for  re- 
covery are  greatly  enhanced. 

The  equation  between  the  bacillary  virulence 
and  the  individual  resistance  of  the  organism  is 
a very  interesting  study  and  one  which  throws 
considerable  light  on  the  prognosis.  An  acute 
form  of  the  disease  is  due  to  infection  by  a 
virulent  strain  of  bacilli  with  normal  or  slightly 
lowered  resistance,  a more  chronic  type  being 
due  to  bacilli  of  slight  virulence  and  normal  re- 
sisting power,  or  virulent  bacilli  and  very  great 


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resisting  power,  etc.  The  short  thick  bacilli 
are  regarded  as  more  virulent  than  the  long 
slender  ones. 

The  presence  of  a healed  lesion  in  the  opposite 
lung  from  the  one  which  shows  activity  speaks 
for  low  virulence  of  bacilli  and  good  resisting 
power  on  the  part  of  the  patient. 

The  activity  present  is  roughly  shown  by  the 
degree  of  moisture  heard  on  auscultation,  and, 
therefore,  much  moisture  over  the  area  involved 
is  of  bad  prognostic  significance.  Involvement 
showing  slight  moisture  speaks  for  fibrosis  and 
carries  a better  prognosis. 

With  marked  or  rapid  tissue  destruction  the 
outlook  is  grave. 

The  character  and  severity  of  symptoms  is 
perhaps  the  chief  point  to  consider,  especially 
when  taken  together  with  the  physical  signs. 
Marked  and  rapid  loss  of  weight  is  generally  a 
bad  prognostic  sign,  unless  the  patient  has  lived 
under  bad  conditions. 

A pulse  markedly  out  of  proportion  to  the 
temperature,  and  which  does  not  respond  in  a 
few  weeks  to  absolute  rest,  is  also  a bad  prog- 
nostic. The  brunt  of  the  burden  in  tubercu- 
losis is  placed  upon  the  heart.  The  fibrous 
tissue  changes  in  the  lungs,  the  plugging  of  the 
numerous  blood  vessels  and  the  displacement  of 
the  heart  and  tugging  on  it  by  adhesions,  all 
form  mechanical  difficulties  for  it  to  overcome. 
In  addition  to  this,  it  shares  in  the  muscular 


weakness  of  the  body  from  the  action  of  the 
toxins  and  has  both  these  factors  to  contend 
with. 

The  temperature  is  of  less  value  than  the 
pulse,  generally  speaking,  and  usually  subsides 
after  a few  months  absolute  rest,  but  occasion- 
ally we  encounter  a case  in  which  high  tem- 
perature persists  even  when  the  lung  condition 
shows  certain  evidence  of  healing.  These  cases 
must  be  ones  in  which  the  heat  controlling 
mechanism  is  faulty,  and  they  do  badly. 

The  power  of  food  assimilation  is  of  the 
utmost  significance.  We  always  feel  hopeful 
when  we  find  the  patient  possesses  a good  gastro- 
intestinal tract,  even  in  advanced  cases.  Very 
often  gastric  disturbances  are  symptoms  of  the 
disease,  and  promptly  disappear  after  proper 
treatment  is  instituted,  but  some  cases  do  well 
even  when  there  is  some  organic  or  serious 
functional  disturbance  present. 

Cough  has  very  slight  significance  so  far  as 
prognosis  is  concerned. 

Pleurisy  is  seen  in  practically  all  cases  at 
sometime  during  the  course  of  the  disease,  but 
unless  dense  adhesions  form  or  it  occasions  con- 
tinued pain,  it  is  of  slight  significance.  Pleu- 
risy with  effusion,  unless  purulent,  does  not  to 
any  extent  modify  the  prognosis. 

Pneumothorax  is  always  a most  serious  com- 
plication. 

Tuberculosis  of  the  larynx,  while  always 
serious,  is  by  no  means  a hopeless  complication, 


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and  if  diagnosed  early  and  properly  treated, 
it  often  gives  most  satisfactory  results.  Tuber- 
culous gastritis  or  enteritis  is  of  the  utmost 
gravity,  although  occasionally  a patient  does 
recover  from  it. 

Nephritis,  either  acute  or  chronic,  arterio- 
sclerosis and  congestive  conditions  of  the  liver, 
add  greatly  to  the  gravity  of  the  situation. 

Of  the  intercurrent  acute  diseases,  pneumo- 
nia and  gTip  are  perhaps  the  most  serious  in 
their  results. 

The  subject  of  prognosis  may  be  briefly  sum- 
marized under  the  following  three  heads : 

1st.  Diagnosis . — ’The  earlier  the  diagnosis 
the  better  the  prognosis,  for  with  a slight  in- 
volvement there  usually  goes  good  recuperative 
power. 

2nd.  Patient . — The  optimistic  individual 
possessed  of  a good  degree  of  intelligence,  who 
fully  realizes  the  gravity  of  the  situation,  and 
who  possesses  a large  amount  of  determination 
and  will  power,  is  the  one  in  whom  we  may  ex- 
pect the  best  results. 

3rd.  Physician  Experience  in  the  manage- 
ment of  the  disease  and  the  careful  attention  to 
the  details  of  treatment  are  of  course  essential, 
but  hopefulness  and  cheerfulness  on  the  part  of 
the  physician,  add  much  toward  the  ultimate 
recovery  of  those  who  are  otherwise  doomed  to 
hopeless  invalidism. 


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